Clinical Praxis and the Place of the Analyst: A Chilean Perspective<Superscript>*</Superscript>

Since its inception, psychoanalytic theory has considered that, conceptually, it is impossible to maintain the division between the individual and society and that the constitution of one necessarily involves the other. Despite this clear legacy of Freudian thought, followed by most of the first and second generations of psychoanalysts, analytic clinical practice started to change almost exclusively into private practice by later generations of psychoanalysts. As a result, a space for information, data gathering, and theoretical production has been gradually configured that is structured in a slanted way. An analytic working environment has thus developed in Chile that tends to eschew contributions from other disciplines that could both enrich and challenge psychoanalytic theoretical–technical developments.     

Thinking about psychoanalytic curricula: an epistemological perspective

The author discusses the role that curriculum development can play in preparing psychoanalytic candidates to understand the challenges created by theoretical pluralism in our field and by the growth of knowledge in neighboring disciplines. Curriculum design can be used to encourage the development of epistemological perspectives that can serve as organizing frameworks to help candidates think critically about psychoanalytic knowledge. It is possible to teach these complex matters in a way that students find accessible and useful. The author presents exemplars taken from the curriculum at the Columbia University Center for Psychoanalytic Training and Research in New York.     

Identification: psychoanalytic and biological perspectives

In recent attempts to bring psychoanalysis into greater contact with other sciences, a number of works have explicated neural science concepts and phenomena--affect, memory, consciousness--for the psychoanalyst. These efforts have helped analysts build a more scientific foundation for their theory and practice. A related task remains--namely, to take psychoanalytic concepts and see how they relate to other sciences. The concept of identification has a long history in psychoanalytic theory. It is seen in parent-child interactions, in teaching and mentoring relationships, and in psychoanalysis and psychotherapy. Neuropsychology and evolutionary biology have explored the phylogenetic precursors of identification, while genetics and infant observation provide insights into individual processes of identification. Finally, neuroscience, particularly recent studies of mirror neurons, offers information about the biological mechanisms of imitation and the relationship of imitation to identification. Findings from these sciences are presented in an effort to further the psychoanalytic understanding of identification, especially its biological underpinnings.     

On the need of fundaments in psychoanalytic thinking

The questions concerning the foundations of psychoanalytic knowledge have been pressing from the beginning. Beside as a therapeutic practice, Freud conceived psychoanalysis as a science, maintaining that like other sciences psychoanalysis should have sound empirical and conceptual fundaments. Freud claimed that there is an inseparable bond (ein Junktim) between cure and acquiring knowledge in psychoanalysis. One of his aims in developing a metapsychology (analogously to metaphysics) was to explicate the conceptual structure of psychoanalytic knowledge. After Freud psychoanalysts have not reached a consensus in the questions concerning the foundations. What kind of foundations does psychoanalytic knowledge need? Are they to be found from the psychoanalytic practice and research on the couch, or rather from metapsychological constructions? In what way should psychoanalysis rely on external scientific research? The article addresses these questions, arguing that even though psychoanalytic work and knowledge do gain justification from various external sources, in the end psychoanalysis stands on its own foundations. It is further argued that especially under the prevailing plurality of theoretical and clinical approaches, psychoanalysis does not have – and does not need – a foundation that could not be further questioned. Thus a coherentist picture of psychoanalysis is defended.     

Reply to Panel Questions

This commentary on papers by Neil Altman and Rachel Peltz argues that while the type of political culture in which one lives has a significant impact on the practice of psychoanalysis, no direct line can be drawn from psychoanalytic theory to any particular political persuasion. It is one thing to argue that psychoanalytic insights offer a way of thinking about political relations; it is quite another to suggest that they can be used to promote or justify a political agenda. While Altman and Peltz theorize about the negative impact of manic defense in contemporary culture, this commentary suggests that there are natural fluctuations in one's ability to respect inner reality and a degree of manic defense employed in everyday life that is quite normal. We all use reality to gain reassurance against death inside. But, when we are “distracted from distraction by distraction” (Eliot, 1971, p. 120) external objects are prematurely deadened so that the needed reassurance through external reality becomes increasingly elusive. Challenging some of Altman and Peltz's political assumptions, the commentary suggests that if psychoanalysis is to contribute to the political realm, it must do so on the basis of how it differs from other approaches to understanding what it means to be a human being.     

Re-enchanting the body: overcoming the melancholy of anatomy

I argue here that Weberian disenchantment is manifest in the triumph of instrumental reason and the expansion of analytic enquiry, which now dominates not simply those sciences upon which medicine depends, but medical practice itself. I suggest ways that analytic enquiry, also referred to here as anatomical reasoning, are part of a particular ideology—a way of seeing, speaking about, and inhabiting the world—that often fails to serve the health of patients because it is incapable of “seeing” them in the moral sense described by Iris Murdoch and others. I use the work of James Elkins and Wendell Berry to call for the recovery of a way of seeing the human body as both other and more than an object of scientific enquiry and social control.     

PSYKOANALYSE I DAG

The original psychoanalytic research situation is the two-person dialogue. However, clinical practice in itself is still not an application of systematic case study methodology. In order to approach the question of why we need systematic psychoanalytic research, three types of dialectical tensions are described. Psychoanalysis, like other scientific disciplines, is involved in a dialectics of (1) rationalism versus empiricism, i.e., theory construction and observation; (2) the perspective from within and from without, i.e., subjective self-knowledge versus expert knowledge; (3) continuity or discontinuity between psychoanalysis and adjacent fields of knowledge, as well as realism versus essentialism. The tension between the scientific and the clinical attitudes is discussed. Finally, the question of scientific and private theories is approached. Some of the methodological and epistemological pitfalls in psychoanalysis are seen as a consequence of the close affinity between private explanatory systems and psychoanalytical theories. Rules of evidence are necessary as a control for the unavoidable uncertainty.     

Genetics,Developmental Psychopathology,and Psychoanalytic Theory: The Case for Ending Our (Not So) Splendid Isolation

This paper considers the historical isolation of psychoanalysis from other scientific academic disciplines. The example of behavior genetics is used to illustrate the potential mutual benefit of cross-fertilization. Exploring links between the two disciplines makes it possible to debate antipsycho-analytic constructions in behavior genetics with greater vigor. At the same time, psychoanalysis, which studies subjectivity, is relevant to a discipline that naively explores the objective environment without considering the crucial mediation through the subjective world. Microbiology and genetics offer models of the mechanisms by which meaning generation and interpretive capacity might interface with the unfolding of genetic expression. Simultaneously, emerging psychoanalytic developmental models have provided an ontogenetic psychological framework that links development of this capacity to the infant-mother relationship. The paper concludes by stressing the need for a cadre of specialist psychoanalytic professionals dedicated to research as the precondition of any meaningful dialogue between psychoanalysis and any other discipline.     

Does anything go? Towards a framework for the more transparent assessment of psychoanalytic competence1

It has been difficult to know what does and does not constitute competent psychoanalytic work and so equally difficult to assess when it is being practised and when it is not. This makes difficult any form of disciplined evaluation of the outcome of training, which has a series of problematic outcomes for psychoanalytic practice, psychoanalytic institutions and the relationship to allied disciplines and professions. In this paper, the author considers how far it might be possible to devise a framework for assessment of training programmes within a disciplined psychoanalytic pluralism. The aspiration is to develop a transparent framework, based on an empirically supported demonstration of analytic capacity. The framework needs to be sensitive and subtle, and to be able to withstand challenge. It needs to take cognisance of the twin facts that there is more than one way to practise psychoanalysis and that it is necessary to avoid ‘anything goes’. Drawing on an ongoing project undertaken by European IPA institutes, the author describes some of the problems colleagues have been experiencing in European institutes, because they have not had available transparent criteria for assessment. He outlines a preliminary form of a proposed method for making more transparent and supportable assessment. The author intends for this paper to inspire hope, enquiry and debate.     

Catching the wrong leopard: courage and masochism in the psychoanalytic situation

This paper introduces the subject of courage into the psychoanalytic discourse about masochism and also demonstrates that ordinary ethical and axiological concerns can and should be included in our psychoanalytic language and practice. At each stage of a psychoanalysis, it may be helpful to consider whether the patient's experience might be that taking a step deeper into the psychoanalytic relationship is both courageous and masochistic. This consideration can open the door to exploration of conscious beliefs and how they are related to unconscious fantasies and assumptions. Considering the possibility that even a sadomasochistic enactment may simultaneously represent a courageous attempt to rework conflict or trauma can enrich the way analysts listen to both manifest and latent material.     

Introduction

This symposium addresses a psychoanalytic lacuna: race. The papers it comprises, drawn from both clinical and academic precincts, pick up the thread of social commentary that runs through the psychoanalytic fabric. Here Psychoanalytic Dialogues joins other like-minded efforts to position the psychic and the social, the clinical and the cultural, in the same discourse, and to consider the painfulness of political inequity amid therapeutic intimacy. These essays demonstrate the clinical and intellectual benefits of the engagement with the disciplines characteristic of psychoanalysis in the previous generation. They also reveal how the evolution of psychoanalytic practice itself potentiates recognition of psychoanalytically marginalized dimensions of society and culture that constitute subjectivity and inform everyday clinical life.     

Ethical and Legal Guidance for Mental Health Practitioners Who Wish to Conduct Research in a Private Practice Setting

Mental health practitioners, even when they have research training, rarely contribute to the scientific literature. One reason for this may be that they need help addressing the ethical and legal issues they encounter as they contemplate undertaking research in a clinical practice setting. To address that need, we offer several types of guidance for conducting research in a private practice setting in a way that meets high ethical and legal standards. We describe the situations in which ethical review of a research proposal by a federally registered institutional review board (IRB) is legally required, and identify alternate mechanisms that practitioners can use to obtain an ethical review when a formal IRB review is not required by law. We discuss legal and ethical requirements of conducting single-case studies in a practice setting. We provide a rationale, and free and inexpensive options, for obtaining a formal certificate of training in human subjects research. And we offer guidance for obtaining informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization from research participants. We conclude with a brief discussion of other legal and professional issues to consider when conducting research in private practice.     

Psychoanalysis and Social Work

Abstract

This paper traces the close relationship between psychoanalysis and social work after Freudian theory's dramatic impact on social work practice in the 1920s. It shows how revisions and expansion of psychoanalytic theory beyond its traditional base influenced clinical work during later decades until the 1960s, when society turned its attention to macrosystems intervention and other theoretical frameworks and practice models. The paper considers the impact of this change in emphasis on clinicians, direct practice, and schools of social work. Although it describes the resurgence of direct practice that occurred in the 1970s and 1980s, it discusses the reasons for the greatly diminished role of psychoanalytic theories in social work curricula. It concludes that there is little reason for optimism about psychoanalysis regaining a prominent position within the profession at the present time and comments on some implications of this state of affairs for those committed to advanced clinical training.     

Teaching psychodynamics in the twenty-first century

A lack of clarity in psychoanalytic education has negatively affected the educational experience of candidates now in training and makes it difficult for prospective candidates to understand the field. Three basic educational concepts--learning objectives, operationalizing, and adult learning theory--can help psychoanalysts teach and assess their students in a clearer, more objective way. Using these concepts has broad implications for both psychodynamic and psychoanalytic education in the twenty-first century.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

Curious bedfellows: Psychoanalytic understanding and old age psychiatry

SUMMARY

The author outlines an approach to assessment, or as she prefers to call it, psychoanalytic consultation, in the Health Service. This involves giving the patient an experience of the analytic process, which they can then assess in a way, while the assessor gains information about a number of categories that can be thought of hierarchically, which inform the advice given the patient and the referrer about management and treatment. The safety of the patient is paramount, as psychoanalytic psychotherapy is a powerful and disruptive treatment. However it is argued that, on the whole, ‘suitability for psychotherapy’ should be on the basis of exclusion rather than involving the patient passing a sort of ‘suitability test’. The latter may enable public psychotherapy services to deny the incompleteness of what they are able to offer.     

国外工作倦怠观的理论探索

目前对工作倦怠的研究主要从社会——文化——历史、生态学、精神分析、行为主义、存在主义等视角来展开的,它们虽各有侧重,但概括来说,这些研究都把重心放在倦息发生的原因、各种症状及其过程的研究上,而对其发生的内在的生理、心理机制涉及甚少,在未来的研究中,应逐步加强这方面的探索。     

Light and color in a void: The analysis of a special needs child

This clinical report comes from the five year, four day a week analysis of a male child. What is special is that this treatment is of a child with marked mental retardation. I have retained this nomenclature because that is how Ricardo's parents described his mental capacity. What they meant was that he was greatly impaired in his cognition and this could be seen in Ricardo's severe cognitive, social, behavioral, and relational improprieties. I have privileged the function of psychoanalytic understanding and the role of transference to bring about modifications in this child's internal world. And I have considered the patient's psychotic mental state to be in need of psychoanalytic treatment not withstanding his psychosis's connection to his cognitive handicap. I have also added information I have received after the analysis, information that demonstrates continued integration coming from the analytic process. Owing to Ricardo's limited mental capacities, this article advances clinical information that is not often found in analyses of children. There are possibly many other children like him who nonetheless would benefit from dynamic psychoanalytic understanding. On the other hand, I shall not discuss this matter theoretically, even though some theoretic considerations are necessary. Clinical practice and the transferential relation are this report's principal material.     

The relevance of Heidegger’s philosophy of technology for biomedical ethics

Heidegger’s thoughts on modern technology have received much attention in many disciplines and fields, but, with a few exceptions, the influence has been sparse in biomedical ethics. The reason for this might be that Heidegger’s position has been misinterpreted as being generally hostile towards modern science and technology, and the fact that Heidegger himself never subjected medical technologies to scrutiny but was concerned rather with industrial technology and information technology. In this paper, Heidegger’s philosophy of modern technology is introduced and then brought to bear on medical technology. Its main relevance for biomedical ethics is found to be that the field needs to focus upon epistemological and ontological questions in the philosophy of medicine related to the structure and goal of medical practice. Heidegger’s philosophy can help us to see how the scientific attitude in medicine must always be balanced by and integrated into a phenomenological way of understanding the life-world concerns of patients. The difference between the scientific and the phenomenological method in medicine is articulated by Heidegger as two different ways of studying the human body: as biological organism and as lived body. Medicine needs to acknowledge the priority of the lived body in addressing health as a way of being-in-the-world and not as the absence of disease only. A critical development of Heidegger’s position can provide us with a criterion for distinguishing the uses of medical technologies that are compatible with such an endeavor from the technological projects that are not.     

Our Literature as the Problem Child of Psychoanalysis Commentary on Paper by Drew Westen

This paper is a response to an essay by Drew Westen. The author agrees with many of Westen's arguments about problems in the psychoanalytic literature and adds that the psychoanalytic literature has always been a problem for psychoanalysis. If we think of psychoanalysis as an ongoing experiment, then its “trials” are all the analytic sessions that have been conducted. Our “literature” has never systematically drawn on those. Westen critically scrutinizes certain habits that, in his view, haunt our literature, but that we do not explicitly note or disown as conceptual contrivances we mean to get rid of, while they are often misguiding clinical thinking and practice. I suggest that a fascinating question riding below the waves of Westen's paper is why patients and analysts accept this situation. I suggest that we all treat psychoanalysis as wisdom, art, relationship, skill, and something other than the application of established scientific findings because we recognize and accept it as that kind of human activity. It is unclear if patients care whether or not their analysts are scientists, but it is clear that analysts are not optimistic about sifting the research literature and finding clear clues to more effective clinical thinking, work, or writing.